published between 2007 and 2010
The authors of the cited article on serosorting in San Francisco, including members of the city’s Public Health Department, have created more problems than they have solved due, in part, to the premature rollout in San Francisco of a campaign to actively “encourage” serosorting as a HIV prevention strategy. That campaign was initiated coincidentally when their article was published in STI by means of...
The authors of the cited article on serosorting in San Francisco, including members of the city’s Public Health Department, have created more problems than they have solved due, in part, to the premature rollout in San Francisco of a campaign to actively “encourage” serosorting as a HIV prevention strategy. That campaign was initiated coincidentally when their article was published in STI by means of a press release, a web based campaign and use of other media. 1-2
“Serosorting” has been variously and vaguely defined, even by the authors themselves. 2-4 It is also subject to radically different public perceptions by the at risk community. Although the STI article refers to it as a rather recent phenomenon in terms of effect on HIV incidence, the campaign acknowledges that this new fangled term describes an obvious behavior, in my view one that is much like natural selection, operating over the last 25 years. Most likely its effect on incidence has always
been a background phenomenon. The web campaign states:
"Since the beginning of the epidemic some gay men have been deciding that they prefer to be with someone of the same HIV status. Many men just feel more comfortable having sex with same status men."
Although the term has a clinically-sounding soothing appeal, cool rational “preference” decision making based on considerate comfort levels seems to be stretching the boundaries to describe the deep fears, emotional anxieties, ignorance of transmission and discrimination characteristic of the epidemic then and now. The authors have not evaluated any psychological or emotional determinants of this practice as a prelude to rollout of public prevention program.
Of great concern is that with the health department’s recognition that the study has significant limitations and “remains a hypothesis that needs validation,” the agency’s Prevention Section moved forward on a serosorting based campaign publicly. The admitted limitations include
lack of clear causality, uncertainty of temporal sequence trends in the different ways data are collected, lack of key biological or behavioral information, alternative hypotheses for explaining HIV incidence and the nature of ecological modeling based studies. To those could be added lack of information about comparative circumcision rates recently shown to affect transmission and suspected to apply also in MSM and differentially in racial or ethnic populations.5 The article data do not describe any population influenced differences.
But there are more serious problems with a rollout of a serosorting prevention campaign. None of the epidemiological or ecological studies have evaluated social and other harms that may be expected. These include
legitimizing stigma against HIV infected individuals and ratifying a “pariah” status, unfairly criticizing committed serodiscordant couples because the campaign message is tantamount to telling them they are in the wrong relationship or engaged in practices that may not work, confusing messaging about the viability of other safe sex practices or the benefits of a responsible healthy sexual relationship with discordant partners. The campaign is also illogical in that the agency did not study or embark
on similar campaigns for other serodiscordant risks such as those for heterosexual HPV status.
Other messages described in this public health initiative are welcome and useful. Increasing knowledge, testing, discussion and disclosure are key elements of a prevention program. Encouraging serosorting – as it is
called today –raises a serious risk of return to objectionable, discriminatory and harmful social behaviors based not on what a person does but simply on who they are.
Community Advisory Board Member, San Francisco Clinical Trials Unit
1. G. Newsom and M. Katz. AIDS Office to Launch new HIV Prevention Campaign. Press release, City and County of San Francisco. November 1, 2006.
3. Mao L, Crawford JM, Hospers HJ, Prestage GP, Grulich AE, Kaldor JM, Kippax SC.. Serosorting" in casual anal sex of HIV-negative gay men is noteworthy and is increasing in Sydney, Australia. AIDS. 2006 May 12;20(8):1204-6
4. Parsons JT, Severino J, Nanin J, Punzalan JC, von Sternberg K, Missildine W, Frost D. Positive, negative, unknown: assumptions of HIV status among HIV-positive men who have sex with men. AIDS Educ Prev. 2006 Apr;18(2):139-49
5. Centers for Disease Control. Male Circumcision and Risk for HIV Transmission: Implications for the United States. December, 2006.